Caring for people with psychoactive substance dependence: nursing student perceptions

Abstracts

This was a qualitative exploratory study aiming to better understand the perceptions of student nurses regarding care of the chemically dependent. Semi-structured interviews were conducted between 2007 and 2009 with 17 nursing students from a public university in the city of São Paulo who were training in specialized services for abusers of alcohol and drugs. The content analysis technique was used, and the discourse evaluation revealed that care for the chemically dependent was considered interesting but difficult and exhausting. A positive outcome noted by the students was that the discussion of theory and experience enabled them to change their perceptions of the issue from a moral model base to a more technical, scientific and ethical one. It was concluded that this teaching strategy can contribute to changing the perceptions of nurses toward these patients.

Drug users; Substance-related disorders; Education, nursing; Students, nursing; Health knowledge, attitudes, practice

Estudo exploratório de abordagem qualitativa cujo objetivo foi conhecer as percepções de estudantes de enfermagem frente ao cuidado do dependente químico. Foram realizadas entrevistas semiestruturadas com 17 estudantes de enfermagem de uma universidade pública da cidade de São Paulo, que desenvolveram estágio em serviços especializados no uso de álcool e drogas, no período de 2007 e 2009.Utilizou-se a técnica de análise de conteúdo e a avaliação das falas permitiu evidenciar que o cuidar do dependente químico foi considerado interessante, porém difícil e desgastante. Como pontos positivos, os estudantes apontaram a discussão sobre a teoria e a vivência, o que possibilitou a transformação das concepções vinculadas a um modelo moral para outras, pautadas em modelos técnicos, científicos e éticos. Concluiu-se que essa estratégia de ensino pode contribuir para a mudança das percepções dos enfermeiros frente a esses pacientes.

Usuários de drogas; Transtornos relacionados ao uso de substâncias; Educação em enfermagem; Estudantes de enfermagem; Conhecimentos, atitudes e prática em saúde

Estudio exploratorio de abordaje cualitativo objetivando conocer las percepciones de estudiantes de enfermería frente al cuidado del dependiente químico. Fueron realizadas entrevistas semiestructuradas con 17 estudiantes de enfermería de una universidad pública de la ciudad de São Paulo, que desarrollaron una pasantía en servicios especializados en abuso de alcohol y drogas, entre 2007 y 2009. Se utilizó la técnica de análisis de contenido; la evaluación de los testimonios permitió demostrar que el cuidado del dependiente químico fue considerado como interesante, aunque difícil y desgastante. Como puntos positivos, los estudiantes señalaron la discusión sobre la teoría y la experiencia, lo que posibilitó la transformación de las concepciones vinculadas a un modelo moral para otras, pautadas sobre modelos técnicos, científicos y éticos. Se concluyó en que dicha estrategia de enseñanza puede contribuir al cambio de las percepciones de los enfermeros frente a tales pacientes.

Consumidores de drogas; Trastornos relacionados con sustancias; Educación en enfermería; Estudiantes de enfermería; Conocimientos, actitudes y práctica en salud

INTRODUCTION

Alcoholism and abuse of psychoactive substances are highly disabling disorders and have a multifactorial etiology that involves genetic, social, psychological and environmental components, among others. The compulsive and uncontrolled consumption of alcohol can have a deleterious effect on the health of the individual as well as on relationships and social positions. The 2002 World Health Report attributes 4.0% of the disease burden and 3.2% of all deaths worldwide to alcohol. Alcohol poses the highest health risk in developing countries with low mortality and the third-highest health risk in developed countries. In the Americas, alcohol is the main risk factor among 27 different disease burden factors evaluated by the World Health Organization^{( 1 )}. The latest home survey on drug use in Brazil, conducted in 2005, revealed that 12.3% of the population is dependent on alcohol, 10.1% on tobacco and 1.2% on marijuana^{( 2 )}. A Brazilian study has demonstrated the existence of a high percentage of alcoholics occupying medical and surgical hospital beds for the treatment of physical ailments^{( 3 )}. Chemical dependence is underdiagnosed in primary care^{( 4 )}.

As they are constantly caring for these clients, nurses must be prepared to recognize and meet their needs. This situation presents specific demands, whether in terms of the psychoactive substances themselves or due to the complications emanating from their use. This also affects nursing students, whose training occurs in practical settings in which the problem of dependence is present. Despite the constant presence of alcohol and other drugs in health services, nurses and students can have difficulties in addressing and managing patients who are dependent on psychoactive substances, which has a detrimental effect on the care received. These difficulties have been clearly identified in the literature^{( 5 - 6 )}. However, few studies on the issue have been conducted in Brazil, and the scarcity of research on nursing graduates is even more pronounced. This situation continues with little or no likelihood of change.

An analysis of the few studies conducted with nursing students in Brazil^{( 6 - 8 )} reveals that alcoholism is among the most despised of diseases, and students' attitudes and representations relating to alcoholism and alcoholics are no different from the general population's. One explanation for these results is the training itself, which generally has not offered sufficient training and information regarding dependence. This fact may contribute to the prevalence of prejudice, negative stereotypes and feelings of inadequacy in dealing with the problem, which leads the student to resent or dislike alcoholism and display negative attitudes toward those dependent on psychoactive substances. On the other hand, contact with these patients during training promotes students' acceptance of the dependent individual, and gradual and continued preparation seems to have the greatest impact on changing attitudes and beliefs during training relating to the issue of chemical dependence ^{( 9 )}.

Such evidence reinforces the need to investigate nurses' training in relation to alcohol and other drug dependence to develop methods that promote a change in students' attitudes as future nursing professionals toward those dependent on psychoactive substances and issues related to dependence^{( 9 )}. This would lead to an improvement in health care provision for these patients in Brazil. Therefore, the aim of this study was to understand nursing students' perceptions on care given to patients with a chemical dependence.

METHOD

This was a qualitative exploratory study. A qualitative approach was chosen because the aim was to explore and understand issues related to the values, beliefs and attitudes of the subjects. Qualitative approaches feature the ability to capture the way in which individuals think and react to particular issues, which facilitates the exploration of complex and unique phenomena^{( 10 )}, such as the perception of nursing students regarding the care of patients who are dependent on psychoactive substances.

The study was conducted from 2007 to 2009 and involved 17 second- and third-year undergraduate nursing students enrolled in a public university in the city of São Paulo, who were undertaking practical activities in specialized alcohol and drug services as a part of the Mental Health and Psychiatric Nursing discipline. Data collection took place between August and October 2009 and was performed by means of a semi-structured interview with closed questions to characterize the participants' thoughts and feelings. The guiding question was Comment on your internship in mental health.

All students who met the inclusion criteria were invited to participate in the study. The meetings were scheduled according to the availability of the students. A sample of 17 students was delimited by theoretical saturation of the data, i.e., collection was terminated when there was no new information or clarification. The interviews were conducted on the institution premises, in a reserved place, ensuring a neutral environment that was quiet and free from interruptions. The interviews were recorded and transcribed verbatim and took on average 30 minutes. To preserve the identity of respondents, we use the letter 'E' in the text followed by a number corresponding to each interview.

The interview technique was used as a data collection tool because this facilitated the discussion of matters of a personal nature, such as complex themes and individual choices, allowing us to obtain information that would not be achieved by any other means of investigation. The fact that the researchers were familiar with the participants and maintained a respectful relationship with them also favored the use of this tool^{( 10 )}.

Ethical procedures for the project were approved by the Ethics Committee on Human Research of the EE, USP under number 830/2009, and participants who agreed to participate voluntarily and to the recording of the interviews signed an informed consent form. At the outset, the purpose of the research was clarified, and students were provided an assurance of confidentiality and anonymity.

The technique adopted for data treatment was content analysis of a categorical-themed type, facilitating description of the content of the participants' statements. In this method, systematic and objective procedures are followed to identify the individual's representations and interpretations regarding the phenomenon - in this case, the care of those dependent on psychoactive substances. This is an interpretive vision of reality based on the viewpoint of the study participants^{( 11 )}. The thematic categories were analyzed to capture from their statements the nursing students' perceptions regarding the care of chemically dependent patients.

RESULTS

Characterization of the participants

Among the 17 participants, only one was male. The mean age was 21.4 years, 41.2% were in their 2nd year of the program, and 64.7% reported no relatives or close friends facing problems pertaining to the use of psychoactive substances. All the participants reported having had undergraduate nursing experience with alcoholics only during their internship in that discipline.

Analysis themes

Analysis of the interviews led to the development of two themes for presentation: difficulties in caring for the chemically dependent and the experience of caring for the chemically dependent during this internship.

Difficulties in caring for the chemically dependent

This theme concerns the difficulties experienced by the participants in terms of structural and subjective factors. Analysis of the statements showed that in expressing their views on caring for the chemically dependent, most students saw this as difficult, especially due to their lack of knowledge about dependence. This is demonstrated in the following statements:

(...) It's hard to care for these patients, as a person and as a student. I think also because we haven't really developed many skills yet (E8); (...) Difficult?... I think it was in dealing with them, especially because we haven't had much practice (E5); (...) Oh, at first it was difficult. But over time I got to know more, to know more about the subject. I think it started to get easier then to interact with the patient (E6).

Students attributed the difficulty of caring for patients who were dependent on psychoactive substances to several factors, including the need to address prejudice and a fear of the unexpected. Not knowing what to expect and their feelings of insecurity caused this internship to be feared by students in many different ways, as illustrated by these statements:

(...) I was afraid of them attacking me (E10); (...) I got a little scared, so could not cope nor {had} any idea what was waiting for me (E13); (...) It wasn't 'what I expected,' I had no idea what I would find there (E1).

As regards difficulty in caring for chemically dependent patients, some survey participants identified the professionals in the field of practice as a complicating factor and associated this with the fact that those professionals were not trained in this specialty and did not address the patients appropriately. Students explained this idea in the following statements:

(...) The difficulty was that we realized that the staff there aren't very integrated. They had no expertise in mental health. They didn't know how to deal with chemically dependent (E12); (...) A difficulty may be that some professionals are a little closed-minded, you know, a little outdated with some of their concepts... (E17).

The motivational stages that the chemically dependent patient passes through were also perceived by students as another factor complicating care, interfering with how the relationship is established between trainee and patient. Study participants alluded to patients in advanced stages of motivation as receptive to communication and the establishment of a relationship, and those without motivation as more reserved and aggressive, not dealing well with the student nor inspiring confidence. One student mentioned the lack of veracity of facts divulged by the patient, and another reported ambivalence toward the illness - a major feature of the chemically dependent patient. The following statements elucidate the relationship between patient and motivational stage:

(...) Intervention is easier with those who are in more advanced stages of motivation (E15); (...) There are some patients who are in the denial stage, so it is difficult, they don't accept the truth (E16); (...) Sometimes you spend the whole morning talking and it was all a lie. You would see from the chart, it was all a lie (E9); (...) They want to accept treatment but bring up a lot of other things that they think are good about using the drug. So I found it a bit difficult to deal with the ambivalence (E3).

The complexity of working with a population abusing psychoactive substances was perceived by the participants. Some revealed that, while recognizing the importance of the experience, they found it difficult to address the problem due to its own peculiarities:

(...) I cannot work with and have concerns about this type of patient... I don't want to get involved any more with this emotional issue. I cannot separate myself well enough (E4); (...) But anyway, I think this patient issue is a little difficult. The more you know, you can inch forward... (E5); (...) The training period was very important, but I don't think I would work in this area (E2).

The experience of caring for the chemically dependent

This theme concerns how students perceived the experience of caring for patients who abuse psychoactive substances. When reporting their experiences during the internship, students stated that caring for patients who are dependent on psychoactive substances can be exhausting.

(...) It's exhausting. They come with a real strong, heavy personal and social history. It tired us out psychologically (E12), (...) It was quite exhausting. At the end of the week it looked like I'd been at the internship for 24 hours a day (E16).

On the other hand, participants recognized the internship as a unique, interesting and fundamental experience during the training of professionals in the field of health. The following excerpts demonstrate this idea:

(...) It is an experience that I will remember for the rest of my life (E16); (...) I liked it a lot, I found it a very rich experience (E1); (...) I thought it was really interesting because I had never come into contact with anyone who abused alcohol or other drugs. It was very important (E5); (...) It was quite interesting, because initially I wasn't very fond of the subject (E6).

Regarding their perceptions before and after contact with the dependent patient, participants made it clear that the experience of the internship changed their perceptions of chemical dependence, which before they had based on moral values and common sense.

(...) Before I didn't have any knowledge and I had a prejudiced view, even working in the healthcare field... (E7); (...) Because there's always that judgment, the person drinks because he's weak, you know, because he can't control himself. Then you realize it's not like that... (E13); (...) You know you shouldn't have this prejudice, but even if you sometimes start with prejudice, you can change it (E2).

In addition to breaking students' prejudices, the experience of caring for this type of patient promoted their increased awareness of the problem of substance abuse, which they came to see as a complex phenomenon that involves not only the individual but also the family and the socioeconomic and cultural context in which these people live, as demonstrated by the following statements:

(...) We came to the realization that the patient's problems are far beyond of what we had imagined, right? The patients have a lot of social and family problems. It goes far beyond the problem of addiction. I think nursing has a lot room to work in this specialty (E14).

The experience of caring for substance-dependent individuals made the students reflect on the importance of the issue of chemical dependence in nursing training, regardless of the specialty to be pursued. The students said that all undergraduates should have direct experience with such patients and lamented the fact that the field of substance dependence has a restricted workload and is not taught in an integrated form within the curriculum, indicating that little attention is given to the issue during undergraduate nursing.

(...) Whatever service we're going to work in someday, we will get people with some kind of chemical dependence (E9); (...) There are few people who have had the opportunity I have had... You don't get to address this issue in the undergraduate program as a whole (E9), (...) This theme should be more explored... You finish the program and no one says anything about this... I think more classes are needed (E3); (...) It was good content. I think more classes are needed (E2).

At the end of the internship, their clinical experience with chemically dependent patients led the participants to see themselves as better prepared to address these people than before.

(...) I feel better than I was before the internship (E12) (...) I think now, yes. After the internship I can deal with it, right? I know how to cope better (E14).

DISCUSSION

Although scientific evidence indicates that little attention is given to the training of nurses on the issue of psychoactive substances^{( 12 - 13 )}, few Brazilian studies have investigated strategies to improve this situation. This study presents data from an intervention that enabled nursing students to gain clinical experience with patients with a chemical dependence, showing that this approach produces satisfactory results, both in preparation for working with these patients and in changing the attitudes and behaviors of the student toward the chemically dependent person.

The analysis of students' attitudes toward caring for the patient who is abusing drugs revealed that the participants initially considered this care to be difficult and demonstrated apprehension in communicating with the patient, whether due to fear, insecurity or prejudice. During the internship, this fear was overcome as theoretical understanding and discussions were deepened. The data suggest that the isolated theoretical training students received before the internship was not enough for preparation and reflection on the subject, as preconceived ideas persisted^{( 9 )}. This fact emphasizes the importance of clinical experience with such patients, an important prerequisite not only for the acquisition of care skills but also in terms of changing perceptions of the chemically dependent person, which should of course be reflected in a better quality of care^{( 1 , 9 )}.

According to the students, the professionals in the service found it difficult to care for the chemically dependent, which leads one to reflect on the training of these professionals, which in the students' view has been unsatisfactory, most likely since graduation. It is possible that the students' perception refers to the perpetuation of a way of caring based on moral explanations for chemical dependence. If the student or new professional enters the service without any training, he would have little preparation for and knowledge of the issue and may ultimately repeat interventions based on the experience of his colleagues, which is not always appropriate^{( 14 )}. Regarding the training deficit of professionals in the field of chemical dependence, a study^{( 8 )} showed that insufficient training of professionals is due to the undergraduate curriculum because the workload allocated to the topic is limited and is not systematically integrated with the curriculum.

The students were able to identify the motivational stages of the patient and attribute the patients' behaviors to scientifically validated evidence taught in the classroom and experienced in practice. This shows that the students have been able to apply their knowledge and consider these sometimes hostile patient behaviors, such as a refusal to be helped, as an expected manifestation of the patient's current stage. This perception is of paramount importance because one of the greatest difficulties in providing dedicated care to patients dependent on psychoactive substances is related to defense mechanisms such as denial, rationalization and projection, which, when not understood by nurses, can hinder patient interaction^{( 9 )}.

The motivational stages were proposed by Prochaska and DiClemente in their Transtheoretical Model for understanding how people change their behavior^{( 15 )}. This model attempts to describe readiness to change and stages of change through which an individual with disorders related to psychoactive substances passes. It is based on the premise that behavior change is a process and that people have different levels of motivation or readiness to change, namely, pre-contemplation, contemplation, determination, action and maintenance. In pre-contemplation, the person does not even realize she has a problem and has no intention of changing her behavior; in contemplation, the person already has some awareness of the problem and is seriously considering changing her behavior; in determination, there have been significant changes in lifestyle and there is engagement in meaningful actions in pursuit of change; and in action, there is less chance of relapse and increased confidence that the process of change can be continued^{( 15 )}.

While appreciating the importance of the internship, some students still feared dealing with a patient who presents resistance after the internship, possibly because they had not overcome their negative beliefs about such patients^{( 14 )}. Studies^{( 11 , 16 )} have shown that dissatisfaction in dealing with patients who use/abuse psychoactive substances may be related to several factors, among them the features that these patients present in the motivational stages, such as irritability, denial and independence, as well as emotional aspects of the students or healthcare professionals, the variable etiology of chemical dependence and the professional's unpreparedness and lack of knowledge. It is noteworthy that education alone is not able to cover the entire problem but may provoke the search for new knowledge and skills that facilitate the practice of care in the future.

Importantly, care of chemical dependents is considered exhausting, demanding constant emotional and intellectual activity, and cannot be practiced by adopting repetitive operational procedures. This exhaustion can be related to the alertness and attention required during nurse-user interactions. This finding helps to overcome the idea that has persisted for a long time that activities developed in the field of mental health and psychiatric nursing, having few concrete tools, require little of the student^{( 16 )}.

The change during the internship in the student's perception of the chemically dependent patient is a positive aspect; whereas before, students' perception was based on commonly held beliefs, after the internship it was based on technical and scientific knowledge. This more positive perception of patients who abuse alcohol and/or other drugs tends to be reflected in care practices: nurses minimize their feelings of inadequacy in dealing with this clientele, a feeling that is commonly found in health professionals.

Caring for the user of psychoactive substances - which necessitates an approach that is not only clinical but also includes a social, psychological and relational analysis - indicates that the student recognizes drug addiction as a multi-causal, multifaceted and multi-relational matter, distancing himself from the minimalist model of the disease^{( 17 - 18 )}. Furthermore, the identification of dependence as multifactorial may indicate that students are aware that they must work in different areas to intervene effectively in the identification, control, treatment, rehabilitation and harm reduction of chemical dependency. The participants noted that the theme of chemical dependency was important regardless of the specialty to be pursued, as these patients are encountered in all fields of care due to problems resulting from dependency (or not)^{( 3 - 4 )}, and a skilled professional is required to diagnose and/or intervene appropriately with those who abuse psychoactive substances.

The students emphasized that not all undergraduates have the opportunity to do an internship in the specific field of chemical dependency in the institution studied; only 20% of students have this experience, and the rest of the students intern in other fields of practice not related to the dependency. The students referred to fears and prejudices in dealing with the addict before the internship. In their statements, the internship was cited as the source of their theoretical deepening and reflection on the topic, which led to their change in perception. However, most nurses finish their general education without this training, which contributes to the perpetuation of practices predicated on stereotypes and common beliefs, imbued with moral rather than scientific values.

The workload allocated to this subject throughout college was considered insufficient because the subject is only discussed in the Mental Health and Psychiatric Nursing class, reaffirming the fact that nursing curricula do not address the use of psychoactive substances in an adequate manner and that the content is not systematized across disciplines in the curriculum or taught in the majority of disciplines that involve mental health. The workload does not enable the nurses to reach an appropriate performance level in their duties regarding this problem^{( 7 - 8 )}. This was perceived by students who judged the workload on the subject to be light and stated that there should be a broader approach to the topic during training.

After theoretical training and practical experience, the attitudes of nursing students became more positive toward the drug user. The participants of this study said that learning occurs more concretely in practice. Although some still did not feel qualified to assist chemically dependent patients, which is understandable given the complexity of this type of patient, they generally acknowledged themselves as being more capable than before the internship.

This study has limitations, such as the fact that students from a single institution were studied and no provision was made for a re-evaluation of the participants in subsequent years to see if the perceptions were maintained over time, which would be desirable in future studies. However, it contributed to the scientific knowledge in the area of nursing education in the specialty of alcohol and drugs, which is little explored in many nursing curricula, especially in Latin America and Brazil.

The study contributes to the development of strategies that can be adopted in the composition of undergraduate curricula that positively influence the perceptions and skills of future nurses regarding psychoactive substance dependence. Furthermore, this study lays important foundations for other investigations in this vast yet unexplored field of Brazilian nursing.

CONCLUSION

The results of this study reveal the perceptions of nursing students when caring for users of alcohol and other drugs. Before the internship, their attitudes were pervaded by fears and prejudices related to a lack of knowledge on the subject, but once the internship was completed, students cited having overcome these initial difficulties and having realized that the addict is a patient who needs specific care. A positive outcome of the study was that during the internship, the discussion of theory and experience facilitated the transformation of perceptions from a moral model toward a technical, scientific and ethical one. The time spent with these users during clinical activities was mentioned as a facilitator of learning that contributed to a change in perceptions that had been often misguided.

Despite the difficulties encountered in proposing nursing curricula that adequately address the issue of psychoactive substance dependence in Brazil, the initiative of providing clinical expertise in a specialized alcohol and drug service, even if limited by time and by the non-systematization of the subject in the undergraduate curriculum, proved to be of utmost importance in the consolidation of content and paradigm shifts; the provision of this training lead the student to reflect on his values and beliefs during graduation, which ultimately lead to the minimization of negative attitudes, prejudices and stereotypes and to the improved support and recognition of care afforded to chemically dependent patients by nurses.

These results reinforce the need to rethink nursing training in the field of psychoactive substance dependence. This study provides evidence for the validity of this teaching strategy as a precursor to a technical and scientific approach to the problem of alcohol and other drug dependence in nursing practice. It is recommended that this strategy be adopted by other nursing educational institutions in Brazil because it is impossible to deny the importance of equipping professionals in this skill area with the ability to face one of the biggest public health problems in Brazil and the world; despite its magnitude, the problem of caring for patients with psychoactive substance dependence has been undervalued in nursing education in Brazil. This is an opportunity to contribute to changing this shortcoming.

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Publication Dates

• Publication in this collection
  June 2013